1. The document discusses the evolution of gonadotropins used in assisted reproduction, including their development from urinary sources to recombinant products. 2. It describes how recombinant gonadotropins provide higher purity and more consistent dosage compared to earlier urinary products, with clinical trials demonstrating similar or improved outcomes. 3. The use of recombinant gonadotropins can offer benefits to patients through features such as pre-filled pens, which may improve compliance and reduce stress associated with treatment.

1. Gonadotropins in Assisted
Reproduction
an evolution perspective
Esteves, 1

2. 1. Infertility: understanding the problem
2. Gonadotropins: better today
3. Taking advantage of new products
Esteves, 2

3. UN Census Estimates, 2008

7. Esteves, 7

8. Patients Doctors Industry

10. 600,000 120,000
600 120
1965 1975 1985 1990 1995
Donors from different regions around the world
2000
Esteves, 10

11. Typical Cycle (long protocol):
Daily SC GnRH-a: x21
FSH/LH: x10-15
hCG: x1
Progesterone: x14
Blood tests: x4-7
Number of sticks: 36-57

12. Psychological burden 49%-26%
Prognosis 40%-23%
Cost of treatment 23%-0%
Relationship/divorce 15%-9%
Physical burden 7-6%
Up to 65% of couples dropout
from IVF without achieving
pregnancy before they
complete 3 cycles1-5
Oocyte retrieval 52%
Embryo transfer 29%
Injections 29%
Physical pain 20%
Blood tests 14%
1. Olivius K t al, Fertil Steril 2004;81:258; 2. Land JA et al, Fertil Steril 1997; 68:278; 3. Schroder AK, et al, RBM Online 2004; 5:600; 4.
Osmanangaoglu K et al, Hum Reprod 2002; 17:2655; 5. Rajkhowa M et al, Hum Reprod 2006; 21:358; 6. Brandes M et al, Hum Reprod 2009;
24:3127; 7. Hammarberg K et al, Hum Reprod 2001; 16:374.
Reasons1,5,6

13. 1. Bassett et al. Reprod Biomed Online 2005;10:169–177
2. Lunenfeld. Hum Reprod Update 2004;10:453–467
CHO, Chinese hamster ovary
Milestones in the development of r-hFSH
1980
D-subunit
sequenced
1983
E-subunit
sequenced
1985
E-FSH gene cloned and
expressed in fibroblasts
1988
Human FSH expressed
in CHO cells
1992
First pregnancy
with r-hFSH
Milestones in the development of gonadotrophins
1940
First hCG
extracted from
human urine
1949
First hMG extracted
from urine pools
1962
Purified u-hMG
(Pergonal®) and u-
hCG (Profasi®)
become available
1980s
First FSH-only
product launched
(Metrodin®)
1993
First highly purified
FSH-only product
launched
(Metrodin HP®)
1995
First r-hFSH
launched
(GONAL-f®)
2000
First r-hLH
launched
(Luveris®)
2001
First r-hCG
launched
(Ovidrel®/Ovitrelle)
2001
Full recombinant
gonadotrophin
portfolio available
2002
First filled-by-mass
product launched
(GONAL-f® FbM)
2008
First
r-hLH+r-FSH
combined
(Pergoveris®)
Gonadotropins: better today

14. 1. Howles. Hum Reprod Update 1996;2:172–191
Secretion of FSH
molecules
Incorporation
into host cell
chromosome
Maturation
Translation
Nucleus
apparatus
Golgi
DDDD
EEEE
Transcription
Endoplasmic
reticulum
Transfection
Expression
vector
Expression
vector
mRNA
produced
Esteves, 14

15. Culture
media
HarvestBioreactor
Cell attachment and
proliferation
r-hFSH production and
secretion
Collection of cell
culture supernatant
medium containing
r-hFSH
In-process QC
Concentration of
supernatant
Chromatographic
purification
steps
Ultrasterile filtration
Characterization
and full QC of
bulk r-hFSH
Esteves, 15

16. Esteves, 16
Key
issues
Quality
Clinical
Efficacy
Patient
conven-
ience
Support
Safety
Gonadotropins: better today

17. Esteves, 17
Gonadotropins: better today
Quality
Patient
conven
- ience
Support
Safety

18. recFSH vs HMG Number of
RCTs
included
Number of
participants
Conclusions Category
Daya et al, 2003 8 607 Significant increase in
odds of clinical
pregnancy for recFSH
A
Van Wely et al, 2003 7 2,128 Insufficient evidence
of a difference in odds
of pregnancy or live
birth
B
Al Inany et al, 2005
8
2,031
Insufficient evidence
of a difference in odds
of pregnancy or live
birth
A
Coomarasamy et al,
2008
7 2,219 Favor HMG
B
1. Daya. Cochrane Review. The Cochrane Library 2003; Issue 1. Oxford Update Software
2. Van Wely et al. Cochrane Database Syst Rev 2003;1:CD003973
RCT, randomized, controlled trialEsteves, 18

19. Esteves, 19
Gonadotropins: better today
Clinical
Efficacy
Patient
conven
- ience
Support
Quality

20. u-hMG HP
(5 batches)
r-hFSH
(follitropin
alfa)
Merck Serono data on file
Molecular
weight
markers
Impurities
cannot be
associated
with a better or
worse outcome
but certainly
are not needed
for COH
Esteves, 20

21. Laboratoire De Spectometrie de MBO – October/2009
From urinary to recombinant
Esteves, 21
FSH
Protein
impurities
hMG HP
Choragon-Ferring Pregnyl-OrganonChoragon-Ferring Pregnyl-OrganonChoragon-Ferring Pregnyl-Organon
30% of impurities
per vial with
39 different
proteins identified
(varied from
batch to batch)
van de Weijer et al. Reprod Biomed Online 2003;7:547–557
Kuwabara Y et al, J Reprod Med 2009; 54:459–466

22. TSE diseases associated with
prions (proteins that become
altered from their normal
state)
Normal prions are present in
various tissues in mammals
Conversion of Normal into
‘defective/ infective’ prions
can occur
ƒ Spontaneously (sCJD, fCJD)
ƒ After ‘infection’ (iCJD, vCJD)
Mis-foldedNormal
Johnson et al. NEJM 1998
Esteves, 22

23. Australia 1996:
Recognizes higher
standards of purity and
safety of recombinants;
Encourages their use over
urinary, human derived.
UK 2003: Metrodin HP
withdrawn
unacceptable risks given
that there are alternatives
Esteves, 23

24. Esteves, 24
Gonadotropins: better today
Clinical
Efficacy
Patient
conven
- ience
Support
Safety

25. 1. Bassett et al. Reprod Biomed Online 2005;10:169–177
Purity
(FSH
content)
Mean specific
FSH activity
(IU/mg protein)
Injected
protein
per 75 IU
(mcg)
hMG < 5% ~100 ~750*
hMG-HP < 70% 2000–2500 ~33*
r-hFSH
Follitropin beta – 7000–10,000 8.1*
Follitropin alfa > 99% 13,645 6.1
Esteves, 25

26. Evidence-based truth:
recFSH is more
potent
↑ 3.1 oocytes
(Bosch, 2008)
↑ 1.8 oocytes
(MERIT, 2006)
↑ 2.8 oocytes
(Hompes, 2007)
Scientific truth:
recFSH is purer
Non urine-
extracted product
Recombinant
technology
Esteves, 26

27. 1. Bassett et al. Reprod Biomed Online 2005;10:169–177
2. Driebergen et al. Curr Med Res Opin 2003;19:41–46
Conventional
Bioassay
High
variability
(~20%)
in vivo (rat)
Novel analitycal
method
Physiochemical
technique
Minimal batch-to-
batch variability
(1.6%)1,2
Menopur; Menogon
Bravelle, Fostimon
Merional, Puregon
Gonal-f FbM
Esteves, 27

28. 0
40
60
80
100
20
Filled by bioassay
75 IU ampoule
Other Gonadotropins
75
IU
Lower limit
60
IU
-20%
Upper limit
93.8
IU
+25%
Filled by Mass (FbM)
75 IU ampoule
Gonal-f FbM
75
IU
Upper limit
+2%
76.5
IU
Lower limit
73.5
IU
-2%
0
40
60
80
100
20

30. Esteves, 30
Gonadotropins: better today
Clinical
Efficacy
Safety
Support
Quality

31. Improve adherence to IVF
Lesson 1: Stress reduction
Medication Strategies
sc rFSH/rLH (pen devices)
Antagonist (vs agonist)
Combine meds (antag + rLH)
sc prefilled hCG
Vaginal progesterone 1x/day
(vs IM)
Minimize blood tests
Esteves, 31
Esteves, 31

32. Keep cool…
Esteves, 32

34. Patient Compliance
Stress Reduction
sc rFSH/rLH (pen devices)
Antagonist (vs agonist)
Combine meds (antag + rLH)
sc prefilled hCG
Vaginal progesterone 1x/day (vs IM)
Minimize blood tests

35. Esteves, 35
Gonadotropins: better today
Clinical
Efficacy
Safety
Patient
conven-
ience
Quality

36. 1. Infertility: understanding the problem
2. Gonadotropins: better today
Esteves, 36

37. Group A (hMG; N=299)
Group B (HP-hMG; N=330)
Group C (r-hFSH; N=236)
Gonadotropin rFSH/hMG
112.5-450 UI
Individualized dose
Agonist (nasal spray): Nafarelin acetate (400 mcg/day; fixed)
Day 1 Day 6
Day
of hCG
Cycle
day 21
Day 2-5 of menses
menses
Vaginal
progesterone
Esteves, 37

38. Outcome Measure HMG
n=299
HP-hMG
N=330
r-hFSH
n=236
P-
value
Total gonadotropin dose (IU) 2,685 2,903 2,268 <0.01
Retrieved oocytes (N) 10.9 10.7 10.8 NS
MII oocytes (N) 8.9 8.9 8.7 NS
2PN fertilization rate (%) 72 72 71 NS
Implantation rate (%) 24 27 23 NS
Live birth rate per cycle (%) 24.4 32.4 30.1 NS
Moderate/severe OHSS(%) 2.3 1.8 1.3 NS
Esteves et al, Reprod Biol Endocrinol. 2009; 7:111

39. 18.7 20.3
53.4*
% Cycles with “Step-down”
during ovarian stimulation
HMG HP-HMG rec-hFSH (fbm)
*P<0.01

40. To achieve a
live birth,
21-52% more
HP-hMG and
hMG was
required
compared
with r-hFSH
0
3.000
7.000
10.000
21.6%
r-hFSH HP-hMG
6,324*
7,739
hMG
9,69052.2%
* Mean total dose per cycle/Live birth rate (≤35 years)

41. 62%
• Incidence of
Infertility (WHO II)
67%
• Infertile Patients with PCOS
(WHO II)
41%
• Prevalence of Patients with PCOS
in Clinical Practice
Treatment Management of Infertility GCC Countries (IPSOS May 2008)
Yeko S.R et al. Fertil Steril 2004; Keck C. et al. RBM Online 2005

42. Batch variability
+20%, -25%
225
270
170
IU
Bioassay
Urinary and Follitropin beta
16.5 mcg
(225 IU)
Filled by Mass
Folitropin alfa (Gonal-f FbM)
Batch variability
rrrr 2%
Risk of OHSS
Poor response

43. 75 IU
(n = 29)
112.5 IU
(n = 31)
150 IU
(n = 26)
187.5 IU
(n = 19)
225 IU
(n = 8)
All
(n = 113)
Embryos
transferred
1.8
(0.6)
1.7
(0.8)
2.1
(0.7)
1.9
(0.6)
1.4
(1.0)
1.8
(0.7)
% implantation
rate
43.3
(44.1)
22.0
(32.7)
35.5
(40.6)
45.4
(40.3)
13.9
(22.2)
33.7
(39.0)
% clinical
pregnancies per
cycle (N)
37.9
(11)
32.3
(10)
46.4
(12)
63.2
(12)
25.0
(2)
41.6
(47)
Severe OHSS (N) 1 1 2
(1.7%)
CONSORT = CONsistency in r-hFSH
Starting dOses for Individualized
tReatmenT: ART results
F Olivennes, CM Howles, A Borini, M Germond, G Trew, M Wikland, F Zegers-Hochschild, H Saunders,
V Alam. Reproductive BioMedicine Online 18: 195-204, 2009.Esteves, 43

44. Gonadotropins
Costs
Quality
Clinical
Efficacy
Patient
conven-
ience
Support
Safety
Esteves, 44

45. Gonadotropins
What do we use in South America?
Data supplied by IMS and REDLARA 2007
-
200
400
600
800
1000
1200
1400
1600
1998 1999 2000 2001 2002 2003 2004 2005
Total r-hFSH Total u-FSH Total hMG/LH
9%
39%
52%
r-hFSH
r-hFSH+hMG
hMG
Esteves, 45

46. Esteves, 46

47. It’s time to change...